Volume 6 Issue 7

Continuing Professional Development: Managing anaphylaxis in the out-of-hospital setting

OverviewThis Continuing Professional Development (CPD) module will explore the most severe form of allergic reactions, anaphylaxis. This will include outlining the definition, prevalence, pathophysiology and paramedic management of the disease. There are a number of self-directed activities to complete as you move through the article together with a list of further resources to expand your research. This article requires the reader to have a basic appreciation of normal physiology associated with the immune system and an appreciation of the general approach to assessing and managing patients in the out-of-hospital, emergency setting before completion.

Spotlight on Research

Airways in out-of-hospital cardiac arrest: systematic review and meta-analysisRecently, paramedic advanced airway interventions (AAI) in cardiac arrest have come under increased scrutiny, and supraglottic devices are becoming a more common choice over intubation where clinically appropriate. This meta-analysis specifically aimed to ascertain if patients who have suffered out-of-hospital cardiac arrest have better long (survival to discharge or to one month) and short (return of spontaneous circulation only or survival to hospital admission) term survival with AAI use, when compared to basic airway interventions (BAI).Meta-analyses can be considered useful when the results of individual trials fail to show a definitive answer to a posed research question. By combining the results of multiple trials and then examining the total data for trends, previously unanswerable questions may be answered.The literature search for the systematic review returned 799 papers and ultimately the meta-analysis incorporated 17 studies (publication dates between 1988–2013 for included papers) involving a total of 388 878 patients of 16 years and older, who suffered a cardiac arrest of non-traumatic origin treated in the out-of-hospital environment. For the purposes of the review BAI was defined as bag valve mask ventilation or mouth-to-mouth, with manual manoeuvres and/or the use of an orophayngeal and/or nasopharyngeal airway. AAI included endotracheal intubation (ETI), all supraglottic airways (SGA), double-lumen airways and trans-tracheal or transcricothyroid membrane airways.‘Comparison of long-term outcomes for ETI versus BAI showed a significant decrease in survival’The short-term survival figures showed no significant difference in the overall odds ratio (OR) between the AAI and BAI groups (OR 0.84, 95% CI 0.62–1.13), although there was a non-significant decrease in odds of ROSC when using AAI (OR 0.78, 95% CI 0.60–1.02). Longer-term odds of survival when using AAI were further reduced (OR 0.49, 95% CI 0.37–0.65). However, this is perhaps unsurprising as several confounding factors exist. Patients that have a poorer prognosis initially may be more likely to receive AAI and this is known as confounding by indication. Also, patients that have rapid ROSC are less likely to receive AAI. The authors explain that while AAI has worse outcomes, it may not be that AAI is harmful, but rather that persons receiving AAI might have a poorer prognosis to begin with and are therefore more likely to fall into the AAI group. Six out of 17 studies did not attempt to adjust/match or balance for confounders, which may cause airway interventions to appear better/worse than the true effect. Unfortunately, there is no known way to assess the magnitude of these confounders.Perhaps what is particularly useful for future paramedic practice given the confounding limitations of AAI vs. BAI, is the review's sub-analysis of ETI and SGA. Comparison of long-term outcomes for ETI vs. BAI showed a significant decrease in survival (OR 0.48, 95% CI 0.36–0.64). Corresponding analysis of SGA vs. BAI demonstrated a further decrease in the odds of survival (OR 0.35, 95% CI 0.28–0.44). However, the meta-analysis excluded all studies that included respiratory arrests, mixed arrests and airway obstructions into their patient recruitments. It could be argued that AAI would make a positive difference in survival for this latter small group of patients but these figures are unlikely to significantly alter the overall results.The authors acknowledge that they found no high-quality evidence comparing AAI to BAI in cardiac arrest and no study included in the meta-analysis accounted for other confounders such as interruptions to chest compressions, delays to defibrillation and hyperventilation. Although this meta-analysis suggests decreased survival when using AAI vs. BAI, caution must be applied to these findings as there is potential for bias due to confounding by indication.The authors make a strong recommendation to undertake a prospective controlled trial to address the limitations of previous research.

An insight into the demands and stressors experienced by Community First Responders

Background:Community First Responders (CFR) are volunteers who respond to appropriate medical emergencies while an ambulance is en route. The emergencies that CFRs attend are situations where stress is inherent, yet little is known of which stressors and demands are present and which are considered to be the greatest attributer to stress experienced.Objective:This survey aims to gain further understanding of the demands and stressors experienced by CFRs.Design:An online survey using a modified NASA-TLX scoring system was distributed to CFRs throughout Scotland (n=535). CFRs were asked to gauge the demands and stressors experienced during a ‘typical’ and their ‘most stressful’ callout, what would be the biggest cause of stress if present and the most stressful time-period during callouts.Results:88 CFRs started the survey with 40 continuing to completion. Frustration that the CFR could not help the patient more was considered to be the biggest stressor for both a typical and most the stressful callout. Emotional demand was the most present demand in a typical callout and mental demand in the most stressful callout. If present, loneliness and isolation was deemed to be the biggest cause of stress for CFRs. Prior to arrival at scene was the most stressful time.Conclusions:This insight provides a valuable appraisal for the Scottish Ambulance Service of the CFR scheme and the concerns and demands experienced by its volunteers. The results also act as a cross-sectional study for research investigating stress alleviation through human-computer interaction in the pre-hospital care domain.

The use of telemedicine technology to support in pre-hospital patient care

Lack of accurate clinical information and availability to expertise at the incident scene can affect patient safety and outcome. The use of technology to capture, transmit and assess patient data and information can be used to ensure better patient outcome and more efficient use of resources. Telemedicine can also be of benefit for ED doctors to discuss emergency situations with paramedics, providing advice in terms of treatment, triage and referral to alternative medical facilities.

A comparison of paramedic practice with that of an emergency care practitioner

This article, following on from the previous article by Gaisford (2014), set out to further quantify the day-to-day work of the modern ambulance service. A particular focus was given to the comparison of emergency care practitioner (ECP) and paramedic practice. Non-patient-identifiable audit data from two consecutive years of practice was analysed and compared, looking in particular at the rates the different clinicians treated patients at scene and referred to specialist units. Seven specific categories of presenting complaint were analysed in depth to illustrate where and why the ECP was performing better than the paramedic at treating patients in the community. The audit of the data showed that in all areas the ECP sends less patients to the emergency department than the paramedic; this was found to be due to both the enhanced range of skills and interventions the ECP has available to him/her as well as the greater level of clinical reasoning and knowledge possessed by the ECP.

ABC of Domestic and Sexual Violence

A number of the ‘ABC’ book series have been reviewed in this section since the Journal of Paramedic Practice was first published, but none have addressed such a challenging and emotive subject such as this. No argument over the subject matter though, as it regrettably reflects the nature of an increasing number of incidents paramedics will be asked to attend.An impressive array of contributors immediately provide some gravitas to this text, as does the revelation that domestic and sexual violence is more prevalent than diabetes or inflammatory bowel conditions—that made me pause for thought. The obvious experience and scope of practice of those who have shaped the content deliver a concise, yet informative, commentary on a difficult area for most people to consider, let alone manage patients who have been subjected to such violence.There is plenty of further reading suggested, case studies help to contextualise the content, but the inclusion of witness statements and the occasional testimony from victims ensure the authors’ reinforce the subject matter emphatically.The text is cleverly interspersed with flow charts as well as illustrations and photographs appropriate to the text. The appendices contain additional useful information and chapter summaries help identify the salient points well. Basic stuff but effective. Practical tips for the clinician are documented in tandem with the more generic theory, all of which helps to provide the reader with a broad, if not in depth, understanding of this challenging subject area. The hallmark of the ‘ABC’ series.It could never be classified as a ‘light’ read but it is certainly relevant to contemporary paramedic practice. If there needs to be a more prominent place for this subject in health care curricula, I suspect this book will be a well-thumbed volume.‘It could never be classified as a ‘light’ read, but it is certainly relevant to contemporary paramedic practice’

Report from the first pre-hospital sepsis conference

North East Ambulance Service NHS Foundation Trust (NEAS) recently hosted the first conference dedicated to pre-hospital sepsis care. This event was attended by a packed audience, with representatives from 11 UK ambulance services, speakers from three countries and leading experts in the field of pre-hospital care.

The future for the professional body

This issue of the Journal of Paramedic Practice features the College of Paramedics’ Strategic Plan. Developed by the College of Paramedics’ Governing Council and Executive team following consultation with the College's membership, it serves as the key reference point for the direction of the College over the next two to five years.

Keep up to date with Journal of Paramedic Practice!

Sign up to Journal of Paramedic Practice’s regular newsletters and keep up-to-date with the very latest clinical research and CPD we publish each month.